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Health History and Intake Form

Please fill out the following form before your scheduled session. 

Welcome to my practice.

Through touch, our body can decipher itself in a way it cannot alone. Therapeutic touch can be a powerful tool. Deane Juhan describes bodywork as a catalyst in asserting our “self-responsibility for much of what we have become and much of what we can become.” The beautiful thing is that we are continually reshaping ourselves and there is always an opportunity to transform. Prosperity is not the disappearance of problems but “continual engagement with the process of finding solutions.” What you feel today, will inform what you can do tomorrow. You are the master. I want to be an active partner in your self-discovery.  Now, let’s get down to business.

Medical History

Please check any condition below that applies to you: Required

Draping will be used during the session – only the area being worked on will be uncovered. 

I, the undersigned, understand that the massage I receive is provided for the basic purpose of relaxation and relief of muscular tension. If I experience any pain or discomfort during this session, I will immediately inform the therapist so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor or other qualified medical specialist for any mental or physical ailment that I am aware of. I understand that massage therapists are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such. Because massage should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions, and answered all questions honestly. I agree to keep the therapist updated as to any changes in my medical profile and understand that there shall be no liability on the therapist’s part should I fail to do so.

Thank you for igniting your healing process with me. As your therapist, I commit to being present with you during our time together. I will endeavor to be sensitive to the feedback I receive during the massage. I do not believe in suffering through a massage. While we can at times lean into pain, I encourage you to let me know right away if my touch goes beyond your pain threshold or is uncomfortable in any way. This experience and relationship will flourish with open communication.  I wish you greater ease, flow, engagement and connection. 🌞😺

Thanks for submitting!

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